Provider Demographics
NPI:1285339291
Name:MOLLHAGEN, ADAM (LLC)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MOLLHAGEN
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 DAWES AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1538
Mailing Address - Country:US
Mailing Address - Phone:616-633-2717
Mailing Address - Fax:
Practice Address - Street 1:1750 GRAND RIDGE CT NE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7043
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022815101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor